Intracytoplasmic sperm injection (ICSI) can be used as part of an in vitro fertilisation (IVF) treatment to help you and your husband to conceive a child.

ICSI is the most successful form of treatment for men who are infertile and is used in nearly half of all IVF treatments (HFEA 2012).

ICSI only requires one sperm, which is injected directly into the egg. The fertilised egg (embryo) is then transferred to your uterus (womb) (HFEA 2009a).

Could ICSI help us?

During ICSI the sperm doesn't have to travel to the egg or penetrate the outer layers of the egg. This means that it can help couples where the man's sperm:

can't get to the egg at all;

can get to the egg, but for some reason can't fertilise it.

ICSI is likely to be recommended if your husband has:

A very low or zero sperm count.

A high percentage of abnormally shaped sperm. This can result in poor motility, which means the sperm can't swim well.

Sperm that can't be ejaculated but can be collected from the testicles or from the duct where sperm is stored (epididymis). This may be needed if your husband has had an irreversible vasectomy or injury.

Problems with getting an erection and ejaculating, due to spinal cord injuries or diabetes, for example (NCCWCH 2013:385, HFEA 2009a).

If you have tried IVF you may move on to ICSI if not enough eggs could be retrieved, or if eggs retrieved for IVF were not successfully fertilised (NCCWCH 2013:385, HFEA 2009a).

Is ICSI the answer for all male fertility problems?

ICSI isn't the solution to every male fertility problem. If your husband has a low sperm count as a result of a genetic problem, this could be passed on to any sons you have together. Your doctor may recommend that your husband has a blood test before you start the ICSI cycle (NCCWCH 2013:387, HFEA 2009a).

Your husband should be offered counselling before and after taking the test to help you through both the decision and the process (NCCWCH 2013:387).

How is ICSI carried out?

As with standard IVF treatment, you will be given fertility drugs to stimulate your ovaries to develop several mature eggs for fertilisation. When your eggs are ready for collection, you and your husband will undergo separate procedures.

Your husband may produce a sperm sample himself by ejaculating into a cup on the same day as your eggs are collected. If there is no sperm in his semen, doctors can extract sperm from him under local anaesthetic. Your doctor will use a fine needle to take the sperm from your husband's:

epididymis, in a procedure known as percutaneous epididymal sperm aspiration (PESA); or,

testicle, in a procedure known as testicular sperm aspiraction (TESA).

If these techniques don't remove enough sperm, your doctor will try another tactic. He'll take a biopsy of testicular tissue, which sometimes has sperm attached. This is called testicular sperm extraction (TESE) or micro-TESE, if the surgery is carried out with a microscope.

TESE is sometimes carried out before the treatment cycle begins, and under local anaesthetic. The retrieved sperm are frozen. Any discomfort felt by your husband should be mild and can be treated with painkillers.

After giving you a local anaesthetic, the doctor will remove your eggs using a fine, hollow needle. An ultrasound helps the doctor to locate the eggs. The embryologist then isolates individual sperm in the lab and injects them into your individual eggs. Two days later the fertilised eggs become balls of cells called embryos.

The procedure then follows the same steps as in IVF. The doctor transplants one or two embryos into your uterus through your cervix using a thin catheter.

The UK's National Institute for Health and Clinical Excellence (NICE) recommends a maximum of two embryos transferred to your uterus whatever your age (NCCWCH 2013:365).

Embryos may be transferred two to three days after fertilisation, or five days after fertilisation. Five days after fertilisation the embryo will be at the blastocyst stage. If you're just having one embryo transferred (called elective single embryo transfer, or eSET), having a blastocyst transfer can improve your chances of a successful, healthy, single baby (Glujovsky et al 2012, NCCWCH 2013:364).

If all goes well, an embryo will attach to your uterus wall and continue to grow to become your baby. After about two weeks, you will be able to take a pregnancy test.

How long does ICSI treatment last?

One cycle of ICSI takes between four weeks and six weeks to complete. You and your husband can expect to spend a full day at the clinic for the egg and sperm retrieval procedures. You'll go back anywhere between two days and six days later for the embryo transfer procedure.

What are the success rates of ICSI?

The success rates for ICSI are very similar to conventional IVF methods (HFEA 2009b). A lot depends on your particular fertility problem and your age. The younger you are, the healthier your eggs usually are, and the higher your chances of success.

What are the advantages of ICSI?

ICSI may give you and your husband a chance of conceiving your genetic child when other options are closed to you.

If your husband is too anxious to ejaculate on the day of egg collection for standard IVF, sperm can instead be extracted for ICSI (NCCWCH 2013:341).

ICSI can also be used to help couples with unexplained infertility. Standard IVF is the usual approach, though, as ICSI and IVF pregnancy rates are very similar and IVF is a less complex treatment (NCCWCH 2013:388).

ICSI doesn't appear to affect the long-term health and development of children conceived via the procedure (NCCWCH 2013:444).

What are the disadvantages of ICSI?

ICSI has been in use for a shorter time than IVF. So experts are still learning about its possible effects.

You may be at a slightly higher risk of your baby being born with a birth defect if you conceive with ICSI or standard IVF (Fortunato and Tosti 2011, NCCWCH 2013:442, Sala et al 2011, Wen et al 2012). However, these problems are not common and the absolute risk of your baby having a problem as a result of ICSI or IVF is low (NCCWCH 2013:443-4). More research is needed to be sure if there is a direct link between fertility treatments and birth defects, as your age and infertility may be related to an increased risk of some problems.

ICSI bypasses the natural selection process of the hardiest sperm reaching the egg first. So there's an increased risk of rare genetic problems carried by sperm, which wouldn't usually have reached the egg, being passed on to the child. Some but not all genetic problems can be tested for before you have the treatment (NCCWCH 2013:387, HFEA 2009c).

ICSI is a more expensive procedure than IVF (NCCWCH 2013:388).

Rest assured that ultrasound scans during early pregnancy will monitor your baby's development. And if you have any worries, you will be able to talk to your consultant.

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